Healthcare Provider Details

I. General information

NPI: 1366910358
Provider Name (Legal Business Name): GARY MICHAEL NEWMAN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6929 MATTHEW PL
SPRINGFIELD VA
22151-3607
US

IV. Provider business mailing address

12704 WIMBLEY LN
WOODBRIDGE VA
22192-5084
US

V. Phone/Fax

Practice location:
  • Phone: 703-813-1800
  • Fax:
Mailing address:
  • Phone: 703-853-3902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306605209
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: